Provider Demographics
NPI:1225064850
Name:MATKOWSKI, JASON STANLEY (LAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:STANLEY
Last Name:MATKOWSKI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4253 N CROSSOVER RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4593
Mailing Address - Country:US
Mailing Address - Phone:479-521-5731
Mailing Address - Fax:479-521-4926
Practice Address - Street 1:2003 SE WALTON BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3725
Practice Address - Country:US
Practice Address - Phone:479-464-8081
Practice Address - Fax:479-464-0674
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA0307064101YM0800X
OK3480101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional